PEER REVIEW OF SIPT ADMINISTRATION

For Completion of Requirements for Certification in Sensory Integration

Including Administering and Interpreting the SIPT

USC/WPS

Name of Person Applying for Certification through USC/WPS:

__________________________________________________________________________________

Date of Peer Reviewed Administration of the SIPT: ________________________________________

Name of Reviewer:  __________________________________________________________________

The above-named reviewer is: (check one)

            ________ certified to administer the SIPT (Certification Number: _________)

            ________ a course 2 participant in the USC/WPS sensory integration courses.

(Check all that apply):

___________  The applicant has reviewed the SIPT Training Video provided by USC/WPS.

___________  The applicant demonstrated satisfactory competency in administrating the SIPT.

___________  The applicant did not demonstrate satisfactory competency in administrating and scoring                                    the SIPT.  The following recommendations have been made: 

                        The applicant will: 

                                    _____  a.   further review the SIPT manual and SIPT administration video.

                                    _____  b.   practice administering the SIPT.

                                    _____  c.   seek another peer review, at a later date, prior to applying for                                                                                  certification.

_________________________________________________          ________________________

            (Applicant)                               (Phone)                                       (Date)

_________________________________________________          ________________________

            (Reviewer)                               (Phone)                                       (Date)